P-031: TRANSITION FROM LONG TERM HIGH DOSE FULL AGONIST OPIOIDS TO BUPRENORPHINE IN THE INPATIENT SETTING FOR PEDIATRIC PATIENTS WITH SICKLE CELL DISEASE: A MODIFIED INDIVIDUALIZED MICRO INDUCTION APPROACH. A SINGLE CENTER EXPERIENCE
Authors: SAAH E., PITTS R., NEW T., STERNER-ALLISON J., GIANNOPOULOS H., GEE B.
Journal: HemaSphere (2022)

Purpose: Sickle cell disease (SCD) has a global incidence of approximately 300,000/yr. About 100000 individuals live with SCD in the US. The hallmark of SCD is anemia, recurrent acute painful Vaso occlusive episodes (VOE’s) and progressive multi-organ involvement. VOE’s begin in infancy (dactylitis) and increase in frequency with age. Prompt administration of short-term full agonist opioids, combined with Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) is the mainstay of VOE treatment. However, a subset of patients will develop chronic pain (CP) beginning early in adolescence. Long term opioid therapy has been used to treat SCD CP due to a lack of available alternatives. LTOT for CP has been proven to have poor efficacy and high toxicity and is associated with reduced quality of life. Buprenorphine is a partial opioid agonist, which physiologically exerts a ‘ceiling effect’ with less opioid related toxicity and thus is a safer option for patients who experience poor efficacy and increased toxicity from LTOT. Materials and methods: From 12/2020 to 02/2022, 10 patients met program eligibility criteria: SCD diagnosis, debilitating CP, receiving >90 morphine equivalents daily, (both outpatient and inpatient totals) with poor analgesic response. Each patient underwent a comprehensive evaluation of SCD status and other comorbidities, a psychological evaluation and participated in several education sessions with their caregiver prior to enrollment. Buprenorphine was initiated using a micro induction regimen that comprised of transdermal Buprenorphine 10mcg/hour or 20 mcg/hour on day 1 and adding buccal Buprenorphine/Naloxone starting on day # 2 or 3 and titrating upwards to individualized requirements. Full opioid agonists were slowly weaned down. Symptoms of withdrawal were monitored using the clinical Opioid withdrawal scale (COWS). Results: Patient were between ages between 12-19 years, with median of 18 years. 7 were Female. All 10 patients were successfully transitioned off LTOT onto a Buprenorphine formulation and none experienced withdrawal symptoms. Of the 10 patients, 7 remain on Buprenorphine beyond 3 months post induction with reductions in both acute care utilization and inpatient hospitalization. Utilization data: 6-months pre buprenorphine: Emergency room (ER) visits ranged from 3-20 with a mean of 9 encounters. Number of inpatient admissions were from 3-10 with a mean of 5.7 and length of stay between 3-19.3 days with a mean of 8.75 days. In the 3-6 months post Buprenorphine: number of ED encounters ranges from 1-7 with a mean of 2.2; the number or admissions range from 0-5 with a mean of 1.6 and length of stay ranged between 0-15 days with a mean of 4.85 days. Conclusion: Pediatric and young patients with SCD on high dose LTOT can be transitioned successfully to buprenorphine in the inpatient setting, using a modified micro induction titration regimen. A system wide multidisciplinary approach to include nursing, emergency department, pharmacy, psychologists and psychiatrists and an education dissemination plan is needed. Both patients and parents need to be ready for an alternative in order to achieve long term success. With the increasing reports of the use of Buprenorphine for CP in SCD, large prospective multi-center clinical trials are warranted. The authors do not declare any conflict of interest